Intensity and treatment of symptoms in 3,030 palliative care patients: A cross-sectional survey of the EAPC Research Network

Objective: This study aimed to describe intensity and treatment of symptoms other than pain in European palliative care units.Patients: A total of 3,030 patients, including 2,064 that used an opioid, were included from 143 palliative care centers, in 21 European countries.Results: Pain was treated with analgesics corresponding to the WHO pain ladder step I (n = 374), II (n = 497), and III (n = 1,567). Frequencies of symptoms observed as moderate or severe were for generalized weakness (50 percent), fatigue (48 percent), anxiety (28 percent), anorexia (26 percent), constipation (18 percent), focal weakness (18 percent), depression (18 percent), and dyspnoea (15 percent). When comparing WHO-groups, cancer diagnoses, metastasis sites, countries, and genders, we found that some of the symptom intensities and treatments differed significantly between subgroups. A majority of patients used drugs for symptom management. Still, more than one-third of patients assessed to have moderate or severe constipation did not receive any treatment. The corresponding numbers for depression, confusion, nausea, vomiting, or anxiety were approaching 40 percent and for poor sleep about 50 percent. Prescription practice of antiemetics, laxatives, and psychotropic drugs varied widely between countries both in terms of preparation and percent of patients receiving a specific treatment.Conclusions: This survey shows that clinically relevant symptoms are frequent and that one-third to half of the patients with a symptom observed as moderate or severe do not receive any treatment aimed to reduce the symptom intensity. Several symptoms and treatments differed between WHO-groups, cancer diagnoses, metastasis locations, countries, and genders. Prescription practice varied between countries both in terms of medication administered and percent of patients receiving specific treatment.

Wound pain

SummaryIn acute and chronic wounds, pain represents a common and central medical problem. Wound pain can be caused by multiple factors, such as macro- or microvascular as well as inflammatory processes.The basic concept of pain management is based on the WHO pain ladder. Often this concept of pain therapy remains insufficient. Apart from the conventionally used anal-getics, there are not yet established guidelines for the use of alternative substances.Ultimately the adequate wound pain therapy must be adjusted to each patient and his comorbidities.

Pain control in the continuity of care

As cancer is earlier diagnosed and its treatments improve, palliative care is increasingly playinga vital role in the oncology population. The concept and the timing of application of palliativecare have evolved in the last decades. The WHO pain ladder and the greater understanding ofappropriate multimodal pain control treatments have dramatically improved the managementof cancer pain. Integration of palliative care, which appears crucial for a proper management ofpatients, can be defined as the provision of palliative care both during curative cancer treatmentand after curative treatment has ceased. Clinical assistance should be delivered by specialisedphysicians in different fields, psychologists and nurses, and should include all aspects of advancedcancercare, from diagnosis to the treatment of symptoms. A further aspect of integration ofpalliative care concerns the role of the continuity of care in acute or emergency contexts bothfor out- and inpatients. Further improvements in the management of cancer pain are needed.First, the WHO ladder should be modified with further steps, like those of interventional paincontrol procedures and techniques, with the aim of being effective also for the small proportion ofnonresponsive patients. Second, more research is needed to find out which interventions aimingto improve continuity of care of cancer patients are beneficial to improve patient, providerand process of care outcomes and to identify which outcomes are the most sensitive to change.Of crucial importance would be the development of a standardised instrument to measure thecontinuity of care in cancer patients.This article is a brief overview on the management of cancer pain, from the pharmacologicaltreatments reported by WHO ladder, to the need for integration and continuity of care.

Acute pain in cancer

Pain in patients with cancer occurs because of a variety of different causes and has both nociceptive and neuropathic pain components. It is essential that a thorough assessment of the pain is carried out in order to institute appropriate treatment. Whilst the WHO Pain Ladder is a good place to start, there are many other treatments available to treat pain in cancer. Any pharmacological or interventional treatment will be more successful if appropriate psychological support is provided.